Hurst Samia A, Hull Sara Chandros, DuVal Gordon, Danis Marion
Department of Clinical Bioethics, National Institutes of Health, Bethesda, Md, USA.
Arch Intern Med. 2005 Mar 28;165(6):639-44. doi: 10.1001/archinte.165.6.639.
A common dilemma that confronts physicians in clinical practice is the allocation of scarce resources. Yet the strategies used by physicians in actual situations of resource constraint have not been studied. This study explores the strategies and rationales reported by physicians in situations of resource constraints encountered in practice.
A national survey of US internists, oncologists, and intensive care specialists was performed by computer-assisted telephone interviews. As part of this survey, we asked physicians to tell us about a recent ethical dilemma encountered in practice. A subset of respondents reported difficulties regarding resource allocation. Transcripts of open-ended responses were coded for content based on consensus.
Of the 600 physicians originally identified, 537 were eligible and 344 participated (response rate, 64%). Internists do not make allocation decisions alone but rather engage in negotiation in their resolution. Furthermore, these decisions are not made as dichotomous choices. Rather they often involve alternative solutions in the face of complexities of both the health care system and situations where limited resources must be allocated. Justice is not commonly the justification for rationing.
Physicians' experiences in situations of resource constraints appear to be more complex than the normative literature on health care rationing assumes. In addition, reasoning about justice in health care seems to play only a small part in clinical decision making. Bridging this gap could be an important step in fostering fair allocation of resources in difficult cases.
临床实践中医生面临的一个常见困境是稀缺资源的分配。然而，医生在实际资源受限情况下所采用的策略尚未得到研究。本研究探讨了医生在实践中遇到的资源受限情况下所报告的策略和基本原理。
通过计算机辅助电话访谈对美国内科医生、肿瘤学家和重症监护专家进行了一项全国性调查。作为该调查的一部分，我们要求医生告诉我们他们最近在实践中遇到的一个伦理困境。一部分受访者报告了在资源分配方面的困难。对开放式回答的文字记录根据共识进行内容编码。
在最初确定的600名医生中，537名符合条件，344名参与了调查（回复率为64%）。内科医生并非独自做出分配决策，而是在解决问题时进行协商。此外，这些决策并非作为二分法选择做出。相反，面对医疗保健系统的复杂性以及必须分配有限资源的情况，它们通常涉及替代解决方案。公平通常不是配给的理由。
医生在资源受限情况下的经历似乎比关于医疗保健配给的规范性文献所假设的更为复杂。此外，医疗保健中的公平推理在临床决策中似乎只起很小的作用。弥合这一差距可能是在困难情况下促进资源公平分配的重要一步。
